A Red Blood Cell Alloantibody Exchange Aims to Protect Vulnerable Populations

Every year, patients receive millions of red blood cell (RBC) units through blood transfusions in the U.S. To do so safely, donor cells must be assessed for compatibility to avoid alloantibody reactions in the recipient, which can induce illness, and even death.¹ The problem is, there is currently no active, centralized database of RBC alloantibody information, or blood transfusion history, that can travel with a patient to all medical facilities.²  This lack of data raises the risk of patients having an incompatible transfusion.

Hence, the American Society of Clinical Pathology (ASCP) and other key organizations in the blood bank community, including the American Society of Hematology, the Association for the Advancement of Blood and Biotherapies, the American Red Cross, and Yale University, have formed a working group to create an RBC Alloantibody Exchange that could centralize this information and decrease the risks.¹

The RBC antibody exchange, “Is a mechanism by which virtually any hospital that has a blood bank information system could see if the patient they're actively taking care of has a history of a blood group antibody or antibodies,” according to one of its founding members, Chris Tormey, MD, FASCP, Professor of Laboratory Medicine, and Yale University School of Medicine Director in Transfusion Medicine and Apheresis Services at Yale-New Haven Hospital in New Haven, Connecticut.

The need for an RBC antibody exchange

The Exchange is so important because these antibodies can become undetectable over time, Dr. Tormey explains. Additionally, when patients come in for care at any healthcare facility, healthcare staff may have little to no idea about a patient’s transfusion history, or antibodies, Dr. Tormey says. “And that information is not easily transported across the electronic medical record. Many times, patients don't even know they harbor these antibodies.”

Many people only learn they have the antibodies the hard way—by having an adverse reaction.

Part of the problem is what Dr. Tormey refers to as a “fractured” process for blood testing, and blood collection and distribution. “So, you have a lot of competing entities like the American Red Cross, America's Blood Centers and independent blood donor centers all supplying blood and doing reference lab testing. There isn't one uniform network of collecting blood, distributing, and doing testing.”

The top goals of the Exchange are to increase the portability of patient information about alloantibodies, to reduce transfusion incompatibility and improve transfusion safety, Dr. Tormey says.

Who does an RBC antibody exchange benefit?

While only about 10% of the population in general possess these alloantibodies, the two most common sources for inducing alloantibodies are those who receive numerous transfusions and pregnant people, Dr. Tormey says.

“When you really drill down on these patients that are getting a large [number] of transfusions as a cornerstone of their care, sometimes you'll see rates of 40% or 50% antibody formation rates in those populations,” he explains.

Individuals with conditions like sickle cell disease (SCD), blood cancers, thalassemia, and myelodysplasia are among those who get the most transfusions.

“SCD predominately affects individuals with Black or African American backgrounds,” according to a 2023 interim report on the RBC Exchange by the HHS. The report added, “This population has a long history of marginalization in the United States that impacts quality of life and health outcomes.”

That same report stated that Black and African American populations have an an incidence rate of roughly one in every 365 newborns diagnosed with SCD and one in every 13 diagnosed with sickle cell trait.

Improving health equity

As a result of the potential ways this Exchange could improve the health of Black Americans, the group recently received an equity award from the U.S. Department of Health and Human Services (HHS).³

This award helps to bring some visibility to the topic that Dr. Tormey hopes will also add momentum to the project. “We were very grateful for the award because just as patients don't recognize that this is a problem, clinicians and hospitals don't recognize this as being a problem either. So, one thing this award did was also improve the recognition of this as a problem and [one] that there's a potential solution to.”

This is especially important to the already marginalized SCD population. “Sickle cell patients are among the most alloimmunized patient populations, disproportionately affected by this problem. And because sickle cell crises can happen highly unpredictably, sickle cell patients will often seek care at more than one facility,” Dr. Tormey says.

He sees the Exchange as having potentially “dramatic improvements for patients with sickle cell disease and their transfusion care” as well as improving the safety with which these patients can be transfused.

Where does the RBC antibody exchange stand today?

While the buy-in for the Exchange continues to grow, it will take time, Dr. Tormey says. Founding member and President of the Exchange, Ronald “George” Hauser, MD, is not only designing the registry but working with the individual manufacturers of the blood bank information systems to implement a patch in their software systems, Dr. Tormey explains. By implementing this patch, the embedding information would then be shared in a cloud-like platform.

“So, the goal at this point is to try and convince as many of those laboratory information system manufacturers that this is a worthwhile effort to take under and to start to implement those patches in their system,” says Dr. Tormey.

It’s hard to put a time frame to its completion or adoption, but Dr. Tormey hopes that within the next five years it may become a reality.

People who want to track its progress or show support can visit www.alloantibody.org/.

“The best thing you can do is become informed about the antibody exchange, about the registry, and then try the best you can to spread the word amongst your little local, regional community about this, to help get the groundswell to see if your hospital or your healthcare system would be potentially supportive of bringing this on board,” he says.

The more momentum the project has, the quicker it can be implemented, and the faster we reach patients in need.

References

1.     “ASCP, Blood Bank Community Developing Nationwide RBC Alloantibody Database to Benefit Patients. Press release. https://www.ascp.org/content/news-archive/news-detail/2022/02/09/ascp-blood-bank-community-developing-nationwide-rbc-alloantibody-database-to-benefit-patients#

2.     Toward the Development of a National Red Blood Cell Antibody Patient Data Exchange (RBCAX): 2023 Interim Report.” US Department of Health and Human Services. (PDF)

3.      “RBC Antibody Exchange Receives HHS Equity Award. ASCP press release. https://www.ascp.org/content/news-archive/news-detail/2023/02/02/rbc-antibody-exchange-receives-hhs-equity-award#